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N IOAQ1 I I Environmental Health DepartmentSAs <br />COU <br />NTYU <br />Greorness grows Frere. <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br />the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billed <br />at the current hourly rate. <br />For this certification to be complete, the operator of the site must include: <br />A statement documenting what corrective actions were taken or will be taken for each violation <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br />Operator's certification <br />Inspection Date: January 08, 2020 Inspected By: JOHN ALANIZ <br />Facility Address: 15453 N THORNTON RD, LODI CERS ID: 10184959 <br />1 certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />Name: Title: <br />Signature: Date: